Directly or indirectly, women and girls are statistically more likely to be affected by Ebola than men. Ebola Deeply spoke with Ugochi Daniels, who heads UNFPA’s Humanitarian Response, about Ebola’s gender bias.

Ebola Deeply: Ugochi, thank you for speaking with Ebola Deeply. Women and girls have been hit particularly hard by the spread of Ebola . How bad is the situation?

Daniels: If you’re a woman in an Ebola-affected country right now, you face a triple threat: You could die from Ebola, you could die during pregnancy or you could die during childbirth. We know that Ebola is affecting women at much higher rates, because women are traditionally caregivers, and we also know that if you’re pregnant, fatality rates for Ebola are much higher – 90 percent. So for pregnant women, Ebola is almost certainly a death sentence.

One of the most common complications during pregnancy is bleeding. If a woman comes to a clinic bleeding, with a fever – typically what pregnant women get with complications – these are also classic signs of Ebola. Service providers, rightly, will say that she needs to be tested first, so it can take a long time for her to get the services she needs.

There aren’t yet any statistics on the impact on maternal mortality. Because the health systems have been so devastated, it’s hard to get records. But from the reports we’re hearing about reduction in use of pregnancy and birth services, things are almost back to how they were three years ago. We’re losing years of progress.

Once we’re able to get a better sense of the data, we’ll also be able to see if maternal mortality rates go back to how they were three or four years ago.

Ebola Deeply: Where are the greatest needs at the moment?

Daniels: Well, let’s start off with what the situation was in each country beforehand, where rates of maternal deaths were high especially in Sierra Leone, which has one of the highest maternal mortality rates in the world.

In Sierra Leone, our data shows a significant drop in women going to seek healthcare, as women are scared that they will contract Ebola in a clinic. The biggest challenge that we’ve had in Guinea is resistance to efforts to prevent Ebola; a lot of the rural communities have, for want of a better word, refused to accept that Ebola is a life-threatening disease.

In all countries, the biggest challenge has been in the more remote areas. Even with the variations across the countries, there’s still a lot of similarity in rural areas. Particularly for reproductive health services, it’s pretty grim all around.

Ebola Deeply: Schools are closed, and we’re hearing reports of a spike in teenage pregnancies. Is this something you’re particularly concerned about?

Daniels: Most certainly. Even before these reports of teenage pregnancies began to come in, we had already anticipated that a situation where markets were collapsing, family income was affected and young people were not in school, would put them at-risk. That creates an environment that is particularly ripe for issues such as teenage pregnancy, especially when where access to family planning is reduced. It’s also an environment that’s inductive for sexual exploitation.

We feared that this might happen. Particularly in Sierra Leone, we’re trying to get some sense of the scope so that we can design activities that are particularly appropriate in this environment.

Ebola Deeply: You mention the potential for sexual exploitation. That’s something we wanted to ask about: In a situation where people are afraid, insecure and concerned about the future, how likely is a rise in gender-based violence?

Daniels: Typically, we know that crisis increases vulnerability and risk of sexual exploitation. Last year, at the “Ending Sexual Violence in Conflict” conference organized in London by the British Foreign Office, governments, UN agencies and NGOs made commitments under the “Call to Action”, to prevent, to not wait for evidence and to act immediately against gender-based violence. During times of crisis, gender-based violence is always one of the least-reported issues. To get good data requires having services in place, and be able to engage with women and allow them to feel comfortable enough to discuss the violence they may have experienced.

Until you’re able to create an environment conducive for women to come forward, you typically won’t get reports. But just because there aren’t reports yet, does not mean it’s not happening; in fact, from other crises, we expect that it would be happening. The difference with Ebola is that, globally, we’ve not experienced a crisis like this one, so we need to better understand the context in which gender-based violence might happen.

Ebola Deeply: As you say, the response to this outbreak has largely been drawn from scratch, because there was very little relevant experience to share around. How has UNFPA’s past work in these countries, and in other crises, shaped its response?

Daniels: Before the outbreak, UNFPA’s work was already focused on strengthening the health systems, training health workers and providing access to reproductive health services. After the crisis, UNFPA has provided personal protective equipment (PPE) to health workers, so they can safely deliver babies. We also have the Mano River Midwifery Initiative, which will ensure that pregnant women and girls can access safe pregnancy services, as well as family planning. Right now, we know that about 1.2 million women of childbearing age in the affected countries need access to family planning. With the focus on Ebola, it is also important to make sure that these services are available for those in need.

We’re also distributing dignity kits – one of UNFPA’s signature inventions that we give out to young women and girls affected in a crisis. They contain basic items for hygiene: soap, toothpaste, comb, slippers, sanitary napkins, underwear, [wrappers], flashlights … we make them culturally specific. They allow women to maintain personal hygiene during crises. Emergency reproductive health kits, specifically for health facilities, contain medicine and supplies for safe deliveries, and clean delivery kits for women who have normal deliveries but limited access to services; these are handed out to local health workers, or to the women themselves.

It’s also important to make sure we have trained health workers; through our Mano River project, we want to mobilize 643 national and international midwives. Getting information out and creating awareness is key to ensuring safe deliveries; women and girls need to know where they can go to access safe services. We also distribute supplies of condoms.

Another key aspect of UNFPA’s work is contact tracing. Otherwise, all of the work that UNFPA has done, and is planning to do, is squarely builds on what we’ve done in the countries beforehand.

Ebola Deeply: The Centers for Disease Control and Prevention (CDC) has released data on the sexual transmission of Ebola . Is there enough awareness among survivors about this?

Daniels: It’s a big concern. All male survivors are given condoms and told they could still be infectious through sexual transmission. In certain areas we have seen a reduction in new infections, and it’s largely because people from those communities have adopted safe behaviors. We know the virus can remain in men’s semen for at least three months after recovery, and it can be sexually transmitted by women.

We recommend that both women and men protect themselves using condoms or to abstain from intercourse. We also know it can be transmitted through breast milk. UNFPA is creating a group of experts to look specifically at the impact of Ebola on sexual and reproductive health. Early in the new year, we hope to have more data on this. Early in the new year, we hope to have more data on this.

Ebola Deeply: It usually takes time to rebuild trust in the wake of crises, and this one has hit health systems hard. Looking ahead to the future, are you concerned that women and girls might be afraid or reluctant to return to health services, even when they are back up and running?

Daniels: Certainly. I can’t over-emphasize the importance of raising awareness in communities. People need to get information about where they can access health services, and it’s important that people receive messages about why they require access to services, and what agencies like UNFPA and others have done to make sure that services are available.

After putting in place services, you still have to generate demand, and that’s based on being in communities and working with these people. That’s what’s really going to be critical to the work we do, to make sure that women and girls feel confident they can go to a health facility, and that they can get the services they need, and be safe.